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an Joaquin County FILE COPY <br /> Enviental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: wwwsigov.org/ehd UNIT IV <br /> Well Permit Application 9�p� W <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEat KNAR —3 AM 10; 19 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work de,Fcribed. This application is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Envt�d��'�y��etNI,Heath`-be`p14ftil'ty <br /> ' tIs!5'I€;Gidh'",dTAL Assessors ' <br /> WELL Location 1599° t 6b FIELD AuE Cross Street 6yFAA VISTA city E TFI 11kiP' c"NParcel# l3?-�YO-03 <br /> PROPERJY Plo Wil I LAAIO ('eMt11Aµ?/ gcl9 M. CEW 1 RAL. ST./ <br /> Owner 'k IEFF 11945G2 CSD Address 5acrc <br /> / City57OLILT tJ 9 Zipp2202 Phone# A y - 6b <br /> C-57 Contractor 9E d•t W7 �f/ AddressZZO N• (GiKT ST Cit dV4A fD Zipl/7(. Lic# 0➢ 2RY phone .S U d - z� <br /> Consultant/Sub Cn'1tr EAeT� IF.cN r 1.1t., Address d9S /ZI✓r�pql�$ AGyy City Lic jZ__phone#�'�0 1 1— Z (;6 <br /> GIS Coordinates:4 r W 57.20 0 „t/ 121 Y 19,�/ ,Townshi <br /> p Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/ BORING (CPT, GEOPROBE HYDROPUNCH, HAND-AUGER,OTHER-) B DESTRUCTION (choose type below) <br /> I SOIL BORING#'�j6tE0/�TA44 S&qi -54 �t 4S C2 aq(f D OVER-BORE. DIAMETER <br /> 0 WELL# I 0 PRESSURE GROUT <br /> B 'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> B EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: B STEEL 0 PVC BOTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS 0 HOSE <br /> B AIR SPARGE/OZONE I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH /6 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County�a�er,, R es and Regulations, and all applicable California State Laws. <br /> Signed x Title/CompanyAI”OL.o(r IST <br /> Print Name ?A4L�.DV l Sail Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: z9 s,t�6 bTsc <br /> WORK PLAN DATED: 06 <br /> Application Accepted By Date Issued Area Ob S�" <br /> Grout Inspection By ate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Zoo l 58 89. ' 26 `I7� <br /> C-57 ✓ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc /V A <br /> EHD 29-02-001 <br /> 6/22/04 <br />